Republic of the Philippines )

Province of Isabela ) S.c.

City of Ilagan )
x- - - - - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I, SHARA MAE DOMINGO RACAZA, of legal age, Filipino,

and a resident of Zone 3, Manaring, City of Ilagan, Isabela, under oath
depose and state:

1. That I am the same person executing this Affidavit;

2. That on 03 December 2021 the Department of Foreign Affairs

Santiago City, Isabela issued a Passport to me with Passport Number
P8377928B;

3. That I kept the said Passport inside my back pack together

with other important documents;

4. That on February 2023, we were robbed at our house and the

thieves were able to get my backpack which contains my passport and
other important documents;

5. Hence, I declare that my passport is already lost and beyond

recovery;

6. That I am executing this affidavit for the purpose of declaring

that my Passport with Passport Number P8377928B is beyond recovery and
therefore lost;

7. That this Affidavit is also executed for the purpose of

requesting the issuance of a new Passport in lieu of the lost one; and

8. That I am executing this Affidavit to attest to the veracity and

truthfulness of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my

signature this 5th day of December 2023 at the City of Ilagan, Isabela.

SHARA MAE DOMINGO RACAZA

Affiant

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 SUBSCRIBE AND SWORN to before me this 5th day of
December 2023, at the City of Ilagan, Province of Isabela. The identity of
the affiant is established by her National ID No. 3562-9473-8612-0580.

MARY GRACE M. CAMMAYO-GAOIRAN

Public Attorney II
Administering Oath
Pursuant to R.A. 9406

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